Re-thinking health and social care

Integrated care opinion piece by David Brindle

Wednesday, November 29, 2017

Preparations for the challenges that the NHS and social care will face this winter have felt almost military. Situation rooms, hourly reporting of bed numbers and a “national clinical escalation panel” all smack of the system being placed on a war footing. Let’s hope the flu jab works.

But just as policy-makers were planning for peace in the latter years of the second world war, even before D-Day, so health and care leaders are looking beyond winter to a future where true integration of services will enable the system to take peaks of demand in its stride and improve outcomes for people across the year.

The jury remains out on whether any of it will deliver the kind of step-change envisaged

David Brindle

Pivotal to this vision in England are the 44 sustainability and transformation partnerships set up to cover the country. Their brief is nothing less than to rethink NHS and social care provision at a local level to make it more fitting for 21st century care needs, supporting people to live independent and fulfilling lives while managing one or more long-term conditions.

Contributing to this work are emerging results from 50 so-called vanguard sites, which since 2015 have been developing new models of care. Eight "accountable care systems", an adapted UK version of accountable care organisations common in the US, are experimenting with the concept of contracting for population health improvement. And for good measure, advanced health and care devolution deals are being tested in Greater Manchester and Surrey.

There’s lots of frenetic activity, then, but the jury remains out on whether any of it will deliver the kind of step-change envisaged in a system still fundamentally predicated on a 1948 model of episodic and curative intervention, notwithstanding repeated tinkering with its apparatus since the mid-1970s.

You can spatchcock structures, forcing together the commissioning and indeed the delivery of services. But if you don’t carry the professionals with you, the end results will be no different.

David Brindle

Can we learn anything from the rest of the UK? Scotland has raced ahead of England in the integration stakes, at least organisationally, by creating a network of 31 “integration authorities” that since April 2016 have been responsible for more than £8 billion health and social care spending previously administered by health boards and local authorities.

More cautiously, Wales has since 2015 put its faith in 22 public service boards, one for each local authority area, tasked with drawing up integrated plans. Councils and their NHS counterparts are mandated to enter formal partnership agreements to implement the plans.

Northern Ireland has long since been there, done that and got the tee-shirt, having had fully integrated health and social care services since 1973. Yet critics say it retains some of the highest dependence on hospital and instutional care in the whole of the UK. Proof, if any were needed, that when it comes to integration, culture is the key.

You can spatchcock structures, forcing together the commissioning and indeed the delivery of services. But if you don’t carry the professionals with you, if you don’t win their hearts and minds, the end results will be no different.